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Natural orifice surgery, also known by the trademarked name of Natural Orifice Transluminal Endoscopic Surgery or NOTES, is sometimes called scarless surgery. Instead of making incisions on the outside of the body, access to an organ or tumor in the gastric or intestinal system can be gained by making an incision through one of the body’s natural orifices (mouth, vagina or colon). Natural orifice surgery is still in experimental stages, but there are patients who have had gallbladders removed via their mouth.
In some surgeries, it makes sense to perform surgery via access from a natural orifice. For instance, tonsillectomies are routinely performed through the mouth. Access to polyps in the colon is through a natural orifice. These have long been considered standard, and they are “scarless” procedures. In fact, the New European Surgical Academy founded NOS, to study all natural orifice surgery, those that have been traditionally performed and these new and experimental versions. NOTES is different, since it means mostly the new versions that were not already being performed through natural orifices, and also specializes in surgeries that would traditionally be performed by gastrointestinal surgeons.
Some patients may be better candidates for natural orifice surgery than others. Proponents of the technique say it could be particularly useful in obese patients because incisions on the outside tend to need to be larger to compensate for the presence of extra or larger fat cells. Removal of organs could also be complicated in people who have had net placed to fix hernias, since some of the net may be cut with incisions, and this could result in needing more hernia repairs in the future. Moreover, proponents of this method believe that not cutting through stomach muscle will speed recovery time for most patients, since pain from these surgeries is largely related to incisions.
Others argue that improvement in laparoscopic techniques makes many forms of natural orifice surgery mostly redundant, and more risky than the tiny incisions required for many laparoscopic procedures. The medical community is divided on this issue, and surgeries of this type have mostly been conducted in Europe and South America, though in 2008, a woman underwent a successful transvaginal appendectomy. The benefit of not cutting through the stomach muscles to access the appendix was appreciated by the patient, who said her soreness after the procedure was minimal.
Though this may change, there are still few experts on experimental natural orifice surgery, and because this is considered an experimental method, it’s a good idea to check with insurance if a surgeon proposes this type of surgery to you, since some insurance companies do not cover any treatments considered experimental. There are surgeons who aren’t completely supportive of natural orifice surgery, or who haven’t committed to an opinion as yet. Some experts would like more areas of this type of surgery defined, and specifically would like to see the issue of internal wound healing and risk of infection from this technique better understood. As more of these surgeries are performed, more data is likely to determine their degree of usefulness and the conditions under which such a surgery might be superior to other surgical methods.
Transvaginal endoscopic appendectomies was published in 2001 under the name of “Operative Culdolaparoscopy: A new Approach combining operative culdsocopy with minilaparoscopy” JAAGL. 2001; 8: 438-441
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